An weakness in a muscle wall, can allow extra pressure and strain to be placed on internal organs, pushing them out of place.
This is a condition known as hernia.
Hernia repair has been around for a long time. That means traditional techniques have been perfected while new options and materials have been developed. While not every technique is right for every hernia, they all have common goals: to provide the strongest repair and least chance of recurrence with the least possible discomfort and quickest recovery.
Listen in as Dr Aaron Schwaab, general surgeon at Stoughton Hospital describes the latest advances in Hernia repair and why you should choose Stoughton Hospital for your care!
Advances in Laparoscopic Hernia Repairs & Post-Op Pain Management
From the Show: Stoughton Hospital Health Talk
Summary:
Air Date: 7/7/16
Duration: 10 Minutes
Transcription:
Melanie Cole (Host): An increased weakness in a muscle wall can allow extra pressure and strain to be placed on internal organs pushing them out of place. This is a condition known as hernia. Repairs have come a long way over the years. My guest today is Dr. Aaron Schwaab. He is a general surgeon at Stoughton hospital. Welcome to the show, Dr. Schwaab. First, tell people what happens when there is a hernia. When is it and how does it happen?
Dr. Aaron Schwaab: Basically, a hernia is a hole or a weakness in the muscle of the abdominal wall. And, they can happen pretty much anywhere in the abdominal wall that is prone to weakness. One of the most common places for a hernia is in the inguinal region or down in the groin. We also can see hernia in the umbilicus or the belly button which is more commonly known as an umbilical hernia. Also, we can see hernias in places that have had previous incisions from other surgery.
Melanie: Are there certain movements, things that we do that could cause a hernia? Speak about some of the causes.
Dr. Schwaab: I believe that mainly, hernias are caused by just inherent weaknesses that we have. When you’re specifically talking about inguinal hernias, men in particular are born with the weakness in that area because of the way we develop in the woman’s uterus and the umbilicus or the belly button. It’s the same thing. These are inherent weaknesses that we’re born with. Over time, they just become weakened and wear out. When I mentioned hernias from other surgeries, that’s actually something that we cause as surgeons. We cut through the muscle and cause a weakness there which then can allow that to develop into a hernia over time. I really don’t think that there’s anything that people could do to prevent hernias. I’ve see hernias just as often in patients who live a more sedentary lifestyle as opposed to patients who are very active. I will tell you that obesity and being overweight is certainly a risk that will increase the patient’s likelihood of developing hernias as they age.
Melanie: Are hernias painful? Would we know if we have one?
Dr. Schwaab: Certainly, they can be painful. They also could be asymptomatic or without pain. They often will present as just a bulge that can be painless. But, just as often, patients will notice the discomfort in that area. As a hernia gets larger, basically, what’s happening is that hole or that weakness is stretching. It allows more of what’s inside of you to bulge through and slide in and out of that weakness. That will typically cause pain for patients.
Melanie: Are there any complications to not getting a hernia repaired?
Dr. Schwaab: There certainly can be complications. The one that we worry about the most is what we are calling “incarceration” or “strangulation”. And, basically, what that is, is the internal organs, usually intestines, will protrude through that weakness or hole in the muscle and become trapped. If they become trapped, that can typically damage the structure by cutting off the blood supply. So, in the most extreme case, the intestine could die in that hernia. But what happens, most likely before that happens is, patients will experience pain and symptoms leading up to that. So, it used to be thought that if someone had a hernia, once it’s diagnosed, you really should fix it immediately. That feeling has changed a little bit. It is really okay to wait and watch a hernia, especially if it’s asymptomatic. But, typically, I tell patients that if it’s limiting them or causing any discomfort, that’s when it’s time to get it fixed.
Melanie: So, let’s explain some of the treatment options for hernia. What was going on in the past? What’s changed?
Dr. Schwaab: Actually, the history of hernia repairs is fascinating. If you look back to the Middle Ages, they would cauterize patients with hernia. So, they would take a big metal iron and just stick it over the hernia and burn the patient with the hope that that would cause enough scar tissue to hold it in. Obviously, that wasn’t very successful and patients would often die from infections and other problems. Thankfully, we’ve advanced beyond that. Many patients, in the past, would wear trusses which were like a belt that helps try and hold the hernia in. And, to some degree, that can be helpful for some patients but, obviously, it’s not a long term solution. Now, we repair hernias surgically and the way hernias that are repaired changed dramatically over time as well.
Melanie: What is different? What do you do for somebody as the first line of defense now if they come to you with a painful or asymptomatic hernia?
Dr. Schwaab: If they truly are asymptomatic and it’s small, I will certainly give them an option that they can continue to watch it and come back if it starts bothering them or seems to be getting larger. But, if we’re going to talk about how we’re going to fix this problem, what I typically like to do is a laparoscopic approach. And, what that means is that rather than making a larger incision over where the hernia is, we make smaller incisions and, basically, using those small incisions, we’re able to minimally, invasively fix that hernia. The difference in those 2 operative techniques is significant in that if you imagine the hernia as a hole in the muscle and what’s happening is things are bulging out through that muscle. The open repair , in most cases, approaches that from the top side and it’s going to put a patch or close that hole on top of the muscle; whereas, the laparoscopic approach is going to go behind that muscle and repair it on the inside. The difference is in the physics and that basically most of the force is trying to push out of that hole. If you are going to repair it on the top side, there’s going to be force that’s working against your repair; whereas, if you repair it in the inside, the natural force of the body are going to hold your repair in place. And, that’s allowed us to change some of the dynamics of how people recover from these hernia repairs.
Melanie: What a great description. That was so beautifully put and very understandable for the listeners. Now, what’s recovery like if you use that laparoscopic approach?
Dr. Schwaab: In the past, where most patients who would get an open hernia repair, it was very common for surgeons, because of what I just mentioned, to tell their patients that for six weeks they cannot do any heavy lifting or straining because, again, when they do that it’s going to put a strain on the repair itself and try on breakdown the repair. The nice thing about doing the repair inside the muscle with laparoscopy is that, again, the force is really just going to help hold our repair in place because it’s pushing. Typically, we’re going to use a piece of mesh to cover the weakness or the hole in the muscle and the body’s natural forces are going to help hold that mesh in place. I actually don’t restrict my patients at all. I kind joke and tell them I don’t care if the day after the surgery, they lift their car over their head, they’re not going to hurt what I’ve done. It doesn’t mean that that won’t cause them some pain and discomfort but they are not going to damage the integrity of the repair. That’s great for people that they could get back to their normal activity, basically, as soon as they are pain free. I’ve been doing it this way for 15 years and really have not found any problems with recurrences in hernias, even for patients who go back to lifting weights within a couple of days after their hernia repair.
Melanie: Wow, that’s amazing. And what do you tell patients about weeks down the line as far as pain management?
Dr. Schwaab: We’ve seen a recent significant advance in that as well. There’s a new medication called EXPAREL, which basically is a long-acting numbing medicine. It’s a numbing medicine called “Marcaine”. It’s similar to Novocain or Lidocaine that we’ve been using for years. Typically, it lasts for about 6 hours when you inject it to someone. This medication has figured out a way to package the Marcaine in little lipid packet, which is kind of a fat packet. When you inject it, it takes 3 to 5 days for it to slowly release the medicine. Now, instead of giving it 6 to 8 hours with pain release, with injection this medication, we could get 3 to 5 days of pain relief. I started using this about a year ago in my hernia repairs and it made a dramatic difference. I would say the majority of patients, when they come back, describe some mild discomfort for a day or two. Really, it’s allowed us to go from patients may be taking 30 pain pills after hernia repair to maybe taking a handful--5 or 6--and get back to work within a couple day, at the most, up to a week. I would say the majority of patients who are able to get back after a long weekend. If we do the surgery on a Thursday or Friday, by Monday or Tuesday they are back to work even if it’s some more physically demanding job. It’s amazing when patients come in and say, “Gosh, I had a hernia repair done 10 years ago and I remember being off work for a month and if I had known that that was only going to be off work for a couple of days, I would have done this ages ago.” It’s really made a big difference for patients.
Melanie: What a fascinating topic, Dr. Schwaab. And in just a last few minutes, give us your best advice for people who think they may have a hernia and why you’re so happy to be at Stoughton Hospital now.
Dr. Schwaab: Great. I appreciate the opportunity to talk to you today. For patients who think they have a hernia, the best place to start is usually with your primary physician. They’ll do a preliminary exam on you and be able to tell you if they feel you need to see a surgeon. Generally, a general surgeon is going to be the doctor that specializes in fixing these hernias. It’s the most common surgery that we do. The primary care doctor would forward you unto us and we would go from there. I’m really excited to be at Stoughton Hospital. As I said, it was a difficult decision to leave my previous practice of 15 years but this community really was in need of a surgeon. It’s a very forward thinking, patient-oriented hospital and I think it’s a great environment to start a new practice and I’m really looking forward to serving the community.
Melanie: Thank you so much for being with us today Dr. Schwaab. You’re listening to Stoughton Hospital Health talk. For more information, you can go to stoughtonhospital.com. That’s stoughtonhospital.com. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): An increased weakness in a muscle wall can allow extra pressure and strain to be placed on internal organs pushing them out of place. This is a condition known as hernia. Repairs have come a long way over the years. My guest today is Dr. Aaron Schwaab. He is a general surgeon at Stoughton hospital. Welcome to the show, Dr. Schwaab. First, tell people what happens when there is a hernia. When is it and how does it happen?
Dr. Aaron Schwaab: Basically, a hernia is a hole or a weakness in the muscle of the abdominal wall. And, they can happen pretty much anywhere in the abdominal wall that is prone to weakness. One of the most common places for a hernia is in the inguinal region or down in the groin. We also can see hernia in the umbilicus or the belly button which is more commonly known as an umbilical hernia. Also, we can see hernias in places that have had previous incisions from other surgery.
Melanie: Are there certain movements, things that we do that could cause a hernia? Speak about some of the causes.
Dr. Schwaab: I believe that mainly, hernias are caused by just inherent weaknesses that we have. When you’re specifically talking about inguinal hernias, men in particular are born with the weakness in that area because of the way we develop in the woman’s uterus and the umbilicus or the belly button. It’s the same thing. These are inherent weaknesses that we’re born with. Over time, they just become weakened and wear out. When I mentioned hernias from other surgeries, that’s actually something that we cause as surgeons. We cut through the muscle and cause a weakness there which then can allow that to develop into a hernia over time. I really don’t think that there’s anything that people could do to prevent hernias. I’ve see hernias just as often in patients who live a more sedentary lifestyle as opposed to patients who are very active. I will tell you that obesity and being overweight is certainly a risk that will increase the patient’s likelihood of developing hernias as they age.
Melanie: Are hernias painful? Would we know if we have one?
Dr. Schwaab: Certainly, they can be painful. They also could be asymptomatic or without pain. They often will present as just a bulge that can be painless. But, just as often, patients will notice the discomfort in that area. As a hernia gets larger, basically, what’s happening is that hole or that weakness is stretching. It allows more of what’s inside of you to bulge through and slide in and out of that weakness. That will typically cause pain for patients.
Melanie: Are there any complications to not getting a hernia repaired?
Dr. Schwaab: There certainly can be complications. The one that we worry about the most is what we are calling “incarceration” or “strangulation”. And, basically, what that is, is the internal organs, usually intestines, will protrude through that weakness or hole in the muscle and become trapped. If they become trapped, that can typically damage the structure by cutting off the blood supply. So, in the most extreme case, the intestine could die in that hernia. But what happens, most likely before that happens is, patients will experience pain and symptoms leading up to that. So, it used to be thought that if someone had a hernia, once it’s diagnosed, you really should fix it immediately. That feeling has changed a little bit. It is really okay to wait and watch a hernia, especially if it’s asymptomatic. But, typically, I tell patients that if it’s limiting them or causing any discomfort, that’s when it’s time to get it fixed.
Melanie: So, let’s explain some of the treatment options for hernia. What was going on in the past? What’s changed?
Dr. Schwaab: Actually, the history of hernia repairs is fascinating. If you look back to the Middle Ages, they would cauterize patients with hernia. So, they would take a big metal iron and just stick it over the hernia and burn the patient with the hope that that would cause enough scar tissue to hold it in. Obviously, that wasn’t very successful and patients would often die from infections and other problems. Thankfully, we’ve advanced beyond that. Many patients, in the past, would wear trusses which were like a belt that helps try and hold the hernia in. And, to some degree, that can be helpful for some patients but, obviously, it’s not a long term solution. Now, we repair hernias surgically and the way hernias that are repaired changed dramatically over time as well.
Melanie: What is different? What do you do for somebody as the first line of defense now if they come to you with a painful or asymptomatic hernia?
Dr. Schwaab: If they truly are asymptomatic and it’s small, I will certainly give them an option that they can continue to watch it and come back if it starts bothering them or seems to be getting larger. But, if we’re going to talk about how we’re going to fix this problem, what I typically like to do is a laparoscopic approach. And, what that means is that rather than making a larger incision over where the hernia is, we make smaller incisions and, basically, using those small incisions, we’re able to minimally, invasively fix that hernia. The difference in those 2 operative techniques is significant in that if you imagine the hernia as a hole in the muscle and what’s happening is things are bulging out through that muscle. The open repair , in most cases, approaches that from the top side and it’s going to put a patch or close that hole on top of the muscle; whereas, the laparoscopic approach is going to go behind that muscle and repair it on the inside. The difference is in the physics and that basically most of the force is trying to push out of that hole. If you are going to repair it on the top side, there’s going to be force that’s working against your repair; whereas, if you repair it in the inside, the natural force of the body are going to hold your repair in place. And, that’s allowed us to change some of the dynamics of how people recover from these hernia repairs.
Melanie: What a great description. That was so beautifully put and very understandable for the listeners. Now, what’s recovery like if you use that laparoscopic approach?
Dr. Schwaab: In the past, where most patients who would get an open hernia repair, it was very common for surgeons, because of what I just mentioned, to tell their patients that for six weeks they cannot do any heavy lifting or straining because, again, when they do that it’s going to put a strain on the repair itself and try on breakdown the repair. The nice thing about doing the repair inside the muscle with laparoscopy is that, again, the force is really just going to help hold our repair in place because it’s pushing. Typically, we’re going to use a piece of mesh to cover the weakness or the hole in the muscle and the body’s natural forces are going to help hold that mesh in place. I actually don’t restrict my patients at all. I kind joke and tell them I don’t care if the day after the surgery, they lift their car over their head, they’re not going to hurt what I’ve done. It doesn’t mean that that won’t cause them some pain and discomfort but they are not going to damage the integrity of the repair. That’s great for people that they could get back to their normal activity, basically, as soon as they are pain free. I’ve been doing it this way for 15 years and really have not found any problems with recurrences in hernias, even for patients who go back to lifting weights within a couple of days after their hernia repair.
Melanie: Wow, that’s amazing. And what do you tell patients about weeks down the line as far as pain management?
Dr. Schwaab: We’ve seen a recent significant advance in that as well. There’s a new medication called EXPAREL, which basically is a long-acting numbing medicine. It’s a numbing medicine called “Marcaine”. It’s similar to Novocain or Lidocaine that we’ve been using for years. Typically, it lasts for about 6 hours when you inject it to someone. This medication has figured out a way to package the Marcaine in little lipid packet, which is kind of a fat packet. When you inject it, it takes 3 to 5 days for it to slowly release the medicine. Now, instead of giving it 6 to 8 hours with pain release, with injection this medication, we could get 3 to 5 days of pain relief. I started using this about a year ago in my hernia repairs and it made a dramatic difference. I would say the majority of patients, when they come back, describe some mild discomfort for a day or two. Really, it’s allowed us to go from patients may be taking 30 pain pills after hernia repair to maybe taking a handful--5 or 6--and get back to work within a couple day, at the most, up to a week. I would say the majority of patients who are able to get back after a long weekend. If we do the surgery on a Thursday or Friday, by Monday or Tuesday they are back to work even if it’s some more physically demanding job. It’s amazing when patients come in and say, “Gosh, I had a hernia repair done 10 years ago and I remember being off work for a month and if I had known that that was only going to be off work for a couple of days, I would have done this ages ago.” It’s really made a big difference for patients.
Melanie: What a fascinating topic, Dr. Schwaab. And in just a last few minutes, give us your best advice for people who think they may have a hernia and why you’re so happy to be at Stoughton Hospital now.
Dr. Schwaab: Great. I appreciate the opportunity to talk to you today. For patients who think they have a hernia, the best place to start is usually with your primary physician. They’ll do a preliminary exam on you and be able to tell you if they feel you need to see a surgeon. Generally, a general surgeon is going to be the doctor that specializes in fixing these hernias. It’s the most common surgery that we do. The primary care doctor would forward you unto us and we would go from there. I’m really excited to be at Stoughton Hospital. As I said, it was a difficult decision to leave my previous practice of 15 years but this community really was in need of a surgeon. It’s a very forward thinking, patient-oriented hospital and I think it’s a great environment to start a new practice and I’m really looking forward to serving the community.
Melanie: Thank you so much for being with us today Dr. Schwaab. You’re listening to Stoughton Hospital Health talk. For more information, you can go to stoughtonhospital.com. That’s stoughtonhospital.com. This is Melanie Cole. Thanks so much for listening.
